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_ Waste Tire Su y & Inspection Report nspection Report Number <br /> Wo <br /> State of California <br /> CIWMB 181 INew04/04) S rvey Form - Page 1 Il — <br /> 1140582 <br /> California Integrated Waste Management Board <br /> Part A-- Survey - _- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i — <br /> I TPID- / J f _ © ( Inspection Type (Fill one) <br /> Site Suffix: J 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SGS --Utw 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (/ Inspected By Inspector <br /> CC ex eK-akJ_ IrGvnC 1 O_V1 k I <br /> Physical Address -3 - G AY►'LL� <br /> I s- Vat C�X V, ►'i Po.A-k wC,�3 <br /> Inspection Date l , � Q Z � / a <br /> I Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> -) a3 0 ® PM O Q PM <br /> - 'Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ?� <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> Latitude <br /> 0 Closed 0 Altered <br /> GPS 0 Hauler ® Indoor <br /> C 1 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ---- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 1 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date FP / M / <br /> m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> & 0 Other: § ; <br /> Comments <br /> �- <br /> Inspection Form Included: 0 <br /> Comments Included: ® -- - <br /> Busine s Rep's Signat re Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X f 2-X A'J+df 31 <br /> 62081 <br /> White Copy:CIWN� Yellow Copy:Operator Pink Copy: EA <br />